Patient safety is a concern within the healthcare domain as it is estimated that tens of thousands of people die annually from preventable medical errors. For over ten years, traditional Human Reliability Analysis (HRA) techniques (e.g., Root Cause Analysis and Failure Mode and Effect Analysis) have been used in hospitals nationwide in an attempt to explain why these errors occur and what can be done to prevent them. Still, patient safety has not improved significantly.
Traditional HRA techniques are limited as analysis tools. They do not consider the context in which workers operate. They are also not based on a valid psychological model that could explain human cognitive function. The Cognitive Reliability and Error Analysis Method (CREAM) is an HRA technique that allows analysts to examine worker actions through the context of performance-shaping factors. The CREAM also employs a cognitive model to explain cognitive failures.
This research used the CREAM to re-analyze events containing identifiable error modes that were previously analyzed by hospital team members using the RCA technique. The results of the re-analyses using the CREAM were compared with the previous analyses from RCA events. Additionally, several RCA events were observed and detailed written narratives of the observations were used to perform further independent analyses by three independent analysts in an effort to calculate inter-rater agreement. The results exposed a gap within categories of causal factors between the two techniques. The CREAM identified organizational factors as contributing to error in the events whereas those factors were either minimized or ignored in the RCA. The results also failed to demonstrate any significant inter-rater agreement among independent analysts performing the CREAM analyses. Due to serious data limitations, detailed analyses using the CREAM were not possible.
|Advisor:||Rantanen, Esa M.|
|Commitee:||Esterman, Marcos, Marshall, Matthew, Mayo, Robert|
|School:||Rochester Institute of Technology|
|Department:||Applied Experimental and Engineering Psychology|
|School Location:||United States -- New York|
|Source:||MAI 50/06M, Masters Abstracts International|
|Subjects:||Medicine, Cognitive psychology, Systems science|
|Keywords:||Healthcare, Human reliability analysis, Medical error, Nyports, Organizational factors, Root cause analysis|
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